Windsor Nursing and Rehabilitation Center of Raymo

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation for resident needs and preferences for one (Resident #1) of 8 residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable and infections for 1 of 1 laundry room and 1 of 6 residents (Resident #1) reviewed or infection control in that:The facility failed to ensure textiles used for cleaning were stored properly to prevent contamination. The facility failed to ensure Resident #1 was provided tracheostomy care using sterile technique. These failures could result in the transmission of infection and illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident and staff member was offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. The facility failed to offer residents and staff the 2025-2026 COVID-19 vaccination. This failure could lead to the contraction and transmission of respiratory illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 1 facility's reviewed for safe and functioning equipment. The facility had 1 of 1 stand-up freezers inoperable. Based on observation on 2/23/2026 at 2:00 pm, the kitchen surveyor noted that the stand-up freezer was broken and inoperable. Based on interview with FSM on 2/23/2026 at 2:00 pm, FSM stated that the freezer has been broken for over a year and that they are storing food in a chest freezer. FSM stated that the work order has been placed in but they have not received a new one. FSM stated that he has to make changes to the menu as some of the food comes bulk from food service company and he does not have the space. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, are reported within established timelines to the administrator of the facility and to the SSA for 5 of 7 residents (Residents #8, #16, #26, #20, #32) reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 5 of 7 residents (Residents #8, #16, #26, #20, #32) reviewed for abuse. The facility failed to ensure unexplained bruises found on Resident #32's right arm and wrist on 12/16/2025 were thoroughly investigated and the results reported. The facility failed to ensure a physical altercation between Residents #16 and #26 on 1/3/2026, in which Resident #26 allegedly scratched Resident #16 on the arm after he attempted to grab her breast, was thoroughly investigated and the results reported. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a medication error rate was not 5 percent or greater. The facility had a medication error rate of 18.51%, based on 5 errors out of 27 opportunities, which involved 3 of 6 residents (Residents #18, #43 and #49) and 3 of 4 staff (LVN A, LVN B, and MA C) reviewed for medication administration and medications errors. The facility failed to ensure the staff administered medications to Residents #18, #43 and #49 timely, according to physician orders, and professional standards. This failure could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure residents were free from significant medication administration errors for 1 of 6 Residents (Resident #18) reviewed for medication administration. Resident #18 was not administered his high blood pressure medication as prescribed. This failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements. The facility failed to store food preparation equipment in sanitary area. The facility failed to store and maintain drink dispensing guns between and during meal services in a sanitary method during survey of facility. This failure could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. 1. Based on observation on 2/23/2026 at 1:45 pm surveyor noted that facility was storing two crockpots in their kitchen chemical closet. Above the crockpots were gallons of degreaser for kitchen use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care (including tracheostomy care), was provided such care, consistent with professional standards of practice for 1 resident (Resident # 1) of 1 resident with a tracheostomy reviewed for respiratory and tracheostomy care. The facility failed to ensure that Resident #1's Tracheostomy humidification with air compressor was at 20 PSI per physician order. The facility also failed to ensure Resident #1's inner canula daily change was completed using sterile technique per medical guidelines for procedure. This failure could affect residents with oxygen therapy and tracheostomy status and could lead to respiratory distress, infection control issues, and even death. Record review of Resident #1's admission Record on 2/23/2026, revealed a [AGE] year-old male admitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans.1. The facility failed to ensure Resident #1's care plan included he was under EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities) due to having an Indwelling/foley catheter.2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 2 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) residents reviewed for EBP.The facility failed to ensure CNA A wore proper PPE during peri-care for Resident #1 who required enhanced barrier precautions (EBP). This failure could place residents at risk of MDRO contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #161, Resident #33, Resident #53, and Resident #15) of 8 residents observed for infection control. 1. The facility failed to post the enhanced barrier precaution sign and no PPE gowns noted in the room or nearby Resident #161's room. 2. During Gtube medication administration for Resident #33, RN K did not sanitize hand after touching the privacy curtain. Then while wearing gloves, he touched the bed remote and with the same pair of gloves, he proceeded to touch the residents Gtube. 3. CNA F failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #53. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 7 Residents (Resident #5 and Resident #12) who were observed for ADL care. 1. CNA D stood while feeding Resident #5 her lunch meal on 12/2/24. 2. CNA D stood while feeding Resident #12 her lunch meal on 12/2/24. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 8 residents (Resident #157 and Resident #27), staff, and the public in that: The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied room for Resident #157 and Resident #27. This failure could affect residents by placing them at risk for diminished quality of life and at risk for burn injuries. Findings Included: Record review of Resident #157's , electronic face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #161) of 8 residents reviewed for care plan completion. The facility failed to complete a baseline care plan that addressed enhanced barrier precautions for Resident #161 within the required 48-hour timeframe of admission. This deficient practice could place newly admitted residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in a locked compartment under proper temperature controls and permit only authorized personnel to have access to the keys for one (Resident #53) of seven residents reviewed for medications. Resident #53 had an unidentified medicated cream in a small plastic cup sitting on his nightstand. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated in the refrigerators and in the dry storage. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 3 residents (Resident #2) reviewed for abuse/neglect. The facility failed to report Resident #2's unwitnessed fall with injury on 01/04/24, where Resident #2 sustained a 4 cm laceration to the back of her head that would not stop bleeding and sent out to the hospital. State Survey Agency was not notified of the fall with injury within 2 hours. The incident occurred on 01/04/24 at 7:30 a.m. and was not reported. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 1 of 3 residents (Resident #1) reviewed for transfers, in that: The facility did not ensure Resident #1's RP was provided with a written bed-hold policy on 11-06-2023 when Resident #1 was transferred to the hospital. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 3 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's unwitnessed fall with injury where Resident #1 sustained a 6 cm laceration to the left side of her eyebrow which required 12 stitches to close to State Survey Agency within 24 hours. The incident occurred on 05/10/2024 at 5:34 p.m. The facility emailed the report on 05/13/2024. This failure could place all residents at increased risk for potential abuse to unreported allegations of abuse and neglect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect. The facility failed to report allegations of resident neglect for Resident #1 to the State Survey Agency within the allotted time frame of 2 hours on 08/07/24 when Resident #1 had a fall at around 5AM and sustained a serious bodily injury (laceration to her head), which required 22 sutures/staples. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to have physician orders for the residents immediate care at time of admission for 1 of 4 residents (Resident #3) reviewed for physician admission orders. The facility failed to have physician orders in place for care/treatment/monitoring of Resident #3's colostomy. This deficient practice could place residents with a colostomy at risk in delay in treatment/care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 Residents (Resident #3) reviewed for medical records accuracy, in that: Resident #3's skin assessment documentation was incomplete. Staff did not document Resident #3's surgical incision. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 Residents (Resident #2) reviewed for medical records accuracy, in that: Resident #2's April and May 2024 Treatment Administration Records documentation was incomplete. Staff did not document or sign off on the administration of physician ordered wound care. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment, to particpate or in experimental research, and to formulate an advance directive for 4 (Resident #37, Resident #40, Resident #20, Resident #58) of 14 residents whose records were reviewed for Out-of-Hospital Do-Not-Resuscitate Order forms in that: 1. The facility did not ensure Resident #40's OOH-DNR form was completed fully and correctly. 2. The facility did not ensure Resident #37's OOH-DNR form was completed fully and correctly. 3. Resident #20 had missing information on the front of their OOHDNR ((Out of Hospital Do Not Resuscitate) form. 4. Resident #58 had missing information on the front of their OOHDNR (Out of Hospital Do Not Resuscitate) form. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to investigate any such allegations, for 1 of 3 residents (R #1) reviewed for incidents/accidents. The facility failed to follow the incidents/accidents policy for an incident on 07/30/23 for R #1. This failure could place residents at risk of further incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for two (Resident #40, Resident #44) of 14 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: 1. The facility failed to develop a care plan to address Resident #40's choice of Do not Resuscitate code status. 2. The facility failed to implement a comprehensive person-centered care plan for Resident #44 addressing 1/4 side rails to bed. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 14 residents ( Resident #58), reviewed for comprehensive care plans in that: Advanced directive code status was not updated for Resident #58 care plan. These deficient practices could affect residents with comprehensive care plans and could result in missed or delayed continuity of care.

Inspectors wroteBased on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 3 of 6 medication carts (Medication cart A) reviewed. Medication cart A contained 1 prescription medication card containing Hydralazine 10mg for Resident #15 that was expired 08/31/2023. The deficient practice could result in a resident receiving a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (CNA) observation for infection control. The facility failed to ensure CNA E performed proper peri-care (incontinent care) for Resident #14. This deficient practice could place resident in the facility at risk for infections due to improper incontinent care.